History Taking of Cardiovascular System-The Essentials.

1. History Taking of Cardiovascular
System-The Essentials
Internal medicine Department
Cardiology unit

2. History taking & physical examination
• Fundamental to accurate diagnosis!
• Cheap, fast, and powerful tools!!

3. The history/Anamnesis taking process..
• History of presenting complaint
• Past medical history
• Drug history
• Family history
• Social history
• Systemic enquiry
• Summarizing
• Provisional diagnosis based on history

4. Presenting complaint
• It’s important to use open questioning to elicit
the patient’s presenting complaint
– “What’s your complaint?” or “Tell me about your
symptoms”
• Allow the patient time to answer, trying not to
interrupt or direct the conversation.
• Facilitate the patient to expand on their
presenting complaint if required.
– “Ok, so tell me more about that” or “Can you explain
what that pain was like?”

5. • A patient with a cardiological problem is likely
to have one or more of six main symptoms:
 chest pain/discomfort
 shortness of breath/dyspnea
 fatigue
 palpitations
 syncope
 edema

6. Other symptoms..
Cough
Hemoptysis
Cyanosis
Claudication
Limb pain
Skin discoloration
can indicate a vascular disorder !!

7. History of presenting complaint
• Onset – When did the symptom start? / Was the onset acute or gradual?
• Duration – minutes / hours / days / weeks / months / years
• Severity – e.g. if symptom is chest pain, how bad is it on a scale of 1 to 10?
• Course – is the symptom worsening, improving, or continuing to fluctuate?
• Intermittent or continuous – is the symptom always present or does it come and go?
• Precipitating factors – are there any obvious triggers for the symptom?
• Relieving factors – does anything appear to improve the symptoms e.g. GTN spray
• Associated features –are there other symptoms that appear associated e.g. fever /
malaise
• Previous episodes – has the patient experienced this symptom previously?

8. Symptoms of pulmonary venous
Congestion
• It is due to stagnation of blood in the pulmonary
veins of the lung due to failure of the left
ventricle or mitral stenosis.
• Lung congestion can manifest itself as:
1. Dyspnea on exertion (ask about its grades)
2. Orthopnea (The patient trying to lie propped up
e.g. using extra pillows).
3. P.ND.
4. Dyspnea at rest (severe cases).
5. Cough and expectoration - Hemoptysis.
6. Acute pulmonary edema

9. Symptoms of Systemic Congestion
• It is due to stagnation of blood behind a failed
right ventricle or due to T.S. or T.I. or due to
obstruction of the venous return to the heart e.g.
Constrictive Pericarditis and Pericardial effusion.
• Systemic congestion can manifest itself as:
1. Pain in the right hypochondrium.
2. Swelling of lower limbs and abdominal
distention due to edema and ascites.
3. Dyspepsia and vomiting due to congestion of the
gastrointestinal tract.

10. Symptoms of low cardiac output
• (The symptoms are usually exertional)
1. Easy fatigue
2. Coldness
3. Dizziness
4. Lack of concentration
5. Sweating
6. Syncopal attacks
7. Oliguria
8. Anginal pain
9. Claudication pain

11. Chest pain
• Pain – if the pain is a symptom, clarify the details of the
pain using SOCRATES acronym.
• Site – where is the pain?
• Onset – when did it start? / sudden vs. gradual?
• Character – sharp / dull ache / burning
• Radiation – does the pain move anywhere else?
• Associations – other symptoms associated with the pain?
• Time course – worsening / improving / fluctuating / time of
day dependent
• Exacerbating / Relieving factors – anything make the
pain worse or better?
• Severity – on a scale of 0-10, how severe is the pain?

12. Palpitation
• Ask about:
1. Relation to exertion.
2. Onset, duration and offset.
3. Regularity.
Symptoms of hypertension
• (Non specific)
1. Headache (occipital)
2. blurring of vision
3. epistaxis.

13. Cyanosis
• Ask about:
a. Age of onset:
 Since birth : Fallot's tetralogy .
 Few years after birth : Fallot's triology.
 In teenager :Eisenminger's syndrome (reversed shunt).
 Above age of 40 years : COPD with or without
CorPulmonale.
b. Cyanotic spells and squatting :Fallot's tetralogy.
c. Differential cyanosis : P.D.A with reversed shunt.
d. Exertional cyanosis: in cases of cardiac shunts or in
cases of a cyanotic Fallot's and interstitial pulmonary
fibrosis

14. Symptoms of embolization
1. Hemiplegia
2. Sudden blindness
3. Painless hematuria
4. Acute abdomen (mesenteric occlusion)
5. Sudden onset of coldness of one limb (acute
ischaemia)

15. Fever
1. Rheumatic fever or rheumatic activity
2. Endocarditis
3. chest infection
4. DV.T.
• Ask about symptoms of other systems:
A. As chest
B. G.I.T.
C. neurological symptoms.

16. The history taking process..
• History of presenting complaint
• Past medical history
• Drug history
• Family history
• Social history
• Systemic enquiry
• Summarizing
• Provisional diagnosis based on history

17. Past medical history (Disease or risk factor)
• Cardiovascular disease:
 Angina
 Myocardial infarction – bypass grafts / stents
 Atrial fibrillation
 Stroke
 Peripheral vascular disease
 Hypertension
 Hyperlipidemia
 Rheumatic fever
• Habits- smoking, alcohol, drugs
• Other medical conditions – e.g. hyperthyroidism
• Surgical history – bypass graft / stents / valve replacements
• Acute hospital admissions? – when and why?

18. Drug history
• Cardiovascular medications:
 Beta blockers
 Calcium channel blockers
 ACE inhibitors
 Diuretics
 Statins
 Antiplatelets
 Anticoagulants
 Glyceryl trinitrate spray (GTN spray)
• Other regular medications
• Contraceptive pill – increased risk of thromboembolic
disease
• Over the counter drugs – NSAIDS / Aspirin
• Herbal remedies – e.g. St John’s Wort – enzyme inducer
(can affect Warfarin levels)
• ALLERGIES – ensure to document these clearly

19. Family history
• Cardiovascular disease at a young age
(for men <55 years old, for women <65 years old in
first degree relatives)– myocardial infarction
• Are the parents still in good health? –
if deceased sensitively determine age and cause
of death
• Any unexplained deaths in young relatives? –
e.g. long QT syndrome / channelopathies

20. Social history
• Smoking – How many cigarettes a day? How many years have they
smoked for?
• Alcohol – How many units a week? – type / volume / strength of alcohol
• Recreational drug use – e.g. Cocaine – coronary artery vasospasm
• Diet – Overweight? Fatty foods? Salt intake? – cardiovascular risk factors
• Exercise – baseline level of patient’s day to day activity
• Living situation:
House/bungalow? – adaptations / stairs
Who lives with the patient? – is the patient supported at home?
Any care input? – what level of care do they receive?
• Activities of daily living:
Is the patient independent and able to fully care for themselves?
Can they manage self hygiene / housework / food shopping?
• Occupation– sedentary jobs – ↑ cardiovascular risk – e.g. lorry driver

21. Systemic enquiry
• Systemic enquiry involves performing a brief screen for
symptoms in other body systems.
• This may pick up on symptoms the patient failed to mention
in the presenting complaint.
• Some of these symptoms may be relevant to the diagnosis
(e.g. reduced urine output in dehydration).

22. Systemic enquiry
• Cardiovascular – Chest pain / Palpitations / Dyspnea / Syncope
/ Orthopnea / Peripheral oedema
• Respiratory – Dyspnea / Cough / Sputum / Wheeze
/ Haemoptysis / Chest pain
• GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia /
Weight loss / Abdominal pain / Bowel habit
• Urinary – Volume of urine passed / Frequency / Dysuria /
Urgency / Incontinence
• CNS – Vision / Headache / Motor or sensory disturbance/ Loss
of consciousness / Confusion
• Musculoskeletal – Bone and joint pain / Muscular pain
• Dermatology – Rashes / Skin breaks / Ulcers / Lesions